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How does WC come up with a figure when they want to settle? - Printable Version

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How does WC come up with a figure when they want to settle? - Toyster16 - 05-27-2014

I have had 3 surgeries on my right knee last one was about five weeks ago it was Multi ligament reconstruction with allograft and still can not put pressure on legg the ligaments were acl, pcl, and mcl. WC wants to settle how do they figure the amount or rates for settlement? I'm in California


RE: How does WC come up with a figure when they want to settle? - 1171 - 05-27-2014

Any part or all of you benefits can be settled.
Permanent disability can be calculated by a complicated formula based on a physician's rating of your permanent impairment.
No settlement can be done until you have reached maximum medical improvement.
More on the process and PD in fact sheets
http://www.dir.ca.gov/dwc/iwguides.html


RE: How does WC come up with a figure when they want to settle? - Toyster16 - 05-27-2014

I believe this is the last surgery but I'm still in the healing and pt process and WC is asking to settle they have not given an amount but are delaying my payments and all requests for knee braces and pt dr. Says he will not sing off for at least 12 months from day of surgery because of the extend of my injury.


RE: How does WC come up with a figure when they want to settle? - 1171 - 05-27-2014

(05-27-2014, 08:17 PM)Toyster16 Wrote: I believe this is the last surgery but I'm still in the healing and pt process and WC is asking to settle they have not given an amount but are delaying my payments and all requests for knee braces and pt dr. Says he will not sing off for at least 12 months from day of surgery because of the extend of my injury.

Get an atty and file for penalties ASAP....looks like they want to play rough.
You can use your health plan for denied benefits.
If you are on good terms with the employer let them know about carrier
Not sure what you mean by a "pt dr." As only a physician can give disability.
From the link I posted use guide 14 to file a complaint with the audit unit--send a copy to the claims manager and your employer.
You can also contact your district atty and ask to file a fraud complaint against them.
You can write to you local state legislator with a complaint about stopping your benefits with a copy to the president of the insurance company and your employer.
Hit 'em back twice as hard!
Save copies of everything and only contact them in writing.





RE: How does WC come up with a figure when they want to settle? - Toyster16 - 05-27-2014

I do have a lawyer and the employer has sold the business. I am thinking they are playing ruff cuz they want to settle. But I don't know if it a good idea to settle with the DR. Wanting to wait a full year. Will they go off of how my knee is right now or how it should heal based on last surgery as far as settlement? Cuz my knee could be ok not 100% but good enough in 6 to 12 months but it could also be back to square one won't know till end of healing and pt. But they want to settle now. So my Q is, is settlement based on current knee status?


RE: How does WC come up with a figure when they want to settle? - 1171 - 05-27-2014

I don't know who/what the "DR." is?
as i said: they can't settle until you are at maximum medical improvement. there is no guessing as to how it will be in the future.
that's why stopping benefits now is/could be illegal.
do you have an atty that is experienced in workers comp?
maybe you don't have all the medical information.
if they are stopping your benefits illegally, they won't quit there--they'll just make something up for a rating.


RE: How does WC come up with a figure when they want to settle? - California_Help - 05-28-2014

(05-27-2014, 08:17 PM)Toyster16 Wrote: I believe this is the last surgery but I'm still in the healing and pt process and WC is asking to settle they have not given an amount but are delaying my payments and all requests for knee braces and pt dr. Says he will not sing off for at least 12 months from day of surgery because of the extend of my injury.

If you are not working due to your injury you should be receiving TTD payments up to 104 weeks. Has this happened, if not you can apply for state disability?

New En Banc decision last week for California which states you do not have to be MMI/P&S to begin receiving PD payments after your TTD payments of 104 weeks end. The case is here.

http://workcompcentral.com/pdf/2014/misc/BrowerEnBanc.pdf

Can I ask how they are denying the brace? Is it denied through Utilization Review?

They determine a rating once you are MMI/P&S however some insurance companies try and settle before. I would discuss this with your attorney as there are several ways to settle.

Again, if you cannot work due to your injury I recommend applying for state disability.


RE: How does WC come up with a figure when they want to settle? - Toyster16 - 05-28-2014

(05-28-2014, 11:00 AM)California_Help Wrote:
(05-27-2014, 08:17 PM)Toyster16 Wrote: I believe this is the last surgery but I'm still in the healing and pt process and WC is asking to settle they have not given an amount but are delaying my payments and all requests for knee braces and pt dr. Says he will not sing off for at least 12 months from day of surgery because of the extend of my injury.

If you are not working due to your injury you should be receiving TTD payments up to 104 weeks. Has this happened, if not you can apply for state disability?

New En Banc decision last week for California which states you do not have to be MMI/P&S to begin receiving PD payments after your TTD payments of 104 weeks end. The case is here.

http://workcompcentral.com/pdf/2014/misc/BrowerEnBanc.pdf

Can I ask how they are denying the brace? Is it denied through Utilization Review?

They determine a rating once you are MMI/P&S however some insurance companies try and settle before. I would discuss this with your attorney as there are several ways to settle.

Again, if you cannot work due to your injury I recommend applying for state disability.


They have not flat out denied the brace they just don't approve it and say something is wrong with their system. I did receive state disability for the first year of my injury and then WC picked up the case I've been getting WC but they now want to settle. My current DR. Has not given a % or rating he says he will not close my case for at least a year from day of surgery (last month). Don't know why WC would want to settle without that info. I have not seen a state Dr. Or a WC Dr. They agreed to let me use the one I had



RE: How does WC come up with a figure when they want to settle? - Bummer Knees - 05-28-2014

Work comp can not settle if you are still receiving medical treatment following your surgery and have not reached MMI.

My injury was bilateral knees with five surgeries, the last one being a total knee replacement. The surgeon told me upfront I would not reach MMI for a year or more following the last surgery.

Once I did reach MMI I was given perament restrictions for the knee and received a rating, only then could settlement tĂ lks begin.


RE: How does WC come up with a figure when they want to settle? - 1171 - 05-29-2014

there are no "state" doctors in california workers comp.
whether an agreed doc or a qualified doc is used they are all private practice physicians.

your doctor doesn't have to close down your treatment to settle.

if you are beyond the 104 weeks of temporary disability payments and have exhausted your SDI time, it may be difficult to wait out the year until your doctor is ready to declare you MMI and provide a rating.

SSDI is available to those with a year or more of disability.
http://www.ssa.gov/disability/